Have you purchased any secured items (electronics, boats, jet ski, appliances, etc.) in the last two years on which you still owe money?YesNo

Have you taken out a loan from a finance company, credit union, bank or any other place and secured the loan by household items or other type of secured collateral?YesNo

Creditors' Names

Estimate balances owed on all other types of debt listed below

$ Medical Bills

$ NSF Checks

$ Credit Cards

$ Misc. Bills

When was the last time you used any of your credit cards? (approx. date)

How much has total owed on cards gone up in the last 12 months?

Have you had any new cards issued in the last 12 months?

Do you anticipate receiving a tax refund?YesNo

How much?

Are you eligible for the Earned Income Credit?YesNo

How much?

List all judgments, lawsuits, liens and garnishments against you.

Special concerns

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Material presented on the Jon B. Clarke website is intended for information purposes only. It is not intended as professional advice and should not be construed as such. The material presented on this site is included with the understanding and agreement that Jon B. Clarke is not engaged in rendering legal or other professional services by posting said material. The services of a competent professional should be sought if legal or other specific expert assistance is required.